03040018 CITY OF CUPERTINO. . ;r*'�asz�x ,>1
BUILDING DIVISION PERMITtLC�ONTRACT®RIRRRRN '®O MA' ION:.
BUILDING ADDRESS: PERMITNO.
10380 MILLER AV JUST WATER HEATERS INC 03040018
OWNER'S NAME: PERMIT ISSUE DATE
AMY MA , 1764 NATIONAL AVE 04/03/2003
IE: SANITARY NO. CONTROL NO.
(510) 293-9901
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDO ELECT' PLUMB MECH
�00 LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm Nal I are licensed under provision,Of of Cesium 9 br mmoP
mbill
with Section 7000)of Dl,hdim 3 of dm Dust..end Profession,Code.and my license is P I N A L E D
In full force and a@0.
'gg
Lt.,..Cl. Ue.4 REPLACE WATER HEATER
3 Date Conracunr
DECLARATION
ARCHITECTS DECLARATION APR 1 R 2003
1 understand my plans sesll he used as publl<moords
jo
Licensed Professorial
OWNER-BUILDER DECLARATION BUILDING
1 hereby.(lien,on I am exempt from N.ConttactCo Code:
License Lew for the
"oO followingmason.(Section 7031.5,Business and PmfeWmu Comae:Any clay of county
$ which its Iss s a permit re construct,the applicant
improve,tloermit t or repair any atrement
F�t„n
PH.I.iuiensedpelmuqulthe thebeislonsof forbe suchPermitLiciensle a eLaw(mement
(cohe mmeslkensed purauenl£o00)of Dislom of dm Cnmmmlminhxnselaw(C Code)to
Sq.Ft. Floor Area Valuation
xC
3$ (commencing I,exemitSp0on7000)theWahfrof the thealeeinesaandPt.AnyrtsCnee)of $870
cut he 7 exempt Burt from and to burs for bj alleged esuftel In Any violation of pp�y 7.7 he
out ee Man by am•ppneanars( permit mbjen,te.ppBcmt t a cowl pen.hy or 3'T5 0 4 7 0 0 Occupancy 1),pe
not more ten five hundred Boller.(S5010).
❑(,
as owner of the pripery,m my employee.with wages u thetriole compenutlem.
will do to work and theswmme I.not Intended otoffcmd for ale(Sec.7044,Business
and Profession,Code:The Contractor.License Law comp not apply in an owner of 502 - FINAL RPII 1!99629ERGY
property who build..,improves thmcon,imd who dees.ucbwwk him.clfer through his 506 - GAS TEST
ownemployead,provided tat such Improvements are noth m iced or offered forme.IL
however,to building or impromnent is sold within one year ofcompletion.the owner• 507 — FINAL PLUMBING
Wilder will lave the burden of proving that he did not build w imprmx for putpoa of
cote.)•
❑1,ea owner of the ptopeny,am exclusively convecting with licensed commatma to
constmm the project(Sec.7044,Business and Professions Code:)The ContncuYs LI- _
cense Law does not apply to an owner of property who builds or Improves thereon,and.
who contracts for such projects with a con r mor(s)licensed pursuant u the Cleurxctors
License law.
❑I am exempt undm 5 .B&P C for thla resson
i
r DauWORKERS COMPENSATION DECLARATION
1 hemby aBhm under penally or perjury one of the following decluetions:im and will maintain a Cenlfcam of Consent u self-huuefor WerkeM1Compen-
,u pmvidetl for by Section 7700 of the labor Code.for On performance of the
wrote for which Ni.permit la Issued.
❑1 hove and will maintain Woher't Compensation In,uranee,u required by Section
77010 of the Labor Code.for the performance of the work mor which this permit Is Issued.
My Workers Compensation Insurance carrier and Policy number art:
Canter. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not he completed if tbe permit is foronchunded dollen(5100)
or mu)
1 comfy that in the performance of the work for which this permit Is Issued,I shell not
employ any person in any mannerso as be become subject to the Workcre Compenudon
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provision,of the Labor Code.you mil
� 0 forthwith comply with such prmhions w this permit hill be deemed revoked.
CONSTRUCTION Is.c ON LENDING lendingagerAGENCY (1
(a—r I horn which this
Nettart its conatmc.31 7.Civg agency far Performance of
Ni the work for which tis permit is issued Isco.7097,Civ,C.1
l0 Q Lenders Name
7 z Lancer.Adan•„
C.7 1 aenify that 1 have read this pplication and term that the above information is
Ik.
connect.1 Agree to comply with all city and county Ordinances and au laws misting In
O builtlingconsWcllen,and hereby authorlm mprnentadves of this city in enter upon the
W ahnve•me thinetl property for Inspection pupuse..
Wo)agree to ssm,Indemnify and keep harmless the City of Cuporlino against
Iag IlablllimajudSmenu.costs and expenses which may in any my&=me against said City
lncoV LUNDERSTANDS APPLICANTAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature of ApplipDau .
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the Cupewnoforum buildingacupaptuorcor handle Health and
u defined by the Cupertino Municipal Code.Chapter 9.12,mtl the Health and Ssfcly
1. i�014calb&
de,Section 25371(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea ❑Ne
Will the applicant or future building occupant use equipment w dcvia..which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air contaminants ss defined by Ne Bay Amp Air Quality Management all new materials for inspection.
dct7
❑Yes Ohio
I have read the haurdousmeurieB requirements underChspmr&95 of the Califor
SafelyCode,Seedons 15505,25577 and 25574.1 underumd thuirusc building
es not currently hew a manl Net it u my responsibility in madly the occupant of theuirements which mostbemetPoorOnissuanceor&CerdEcateorampancy, Signature of Applicant Date
ner.rmternxa.gent Dam All roof coverings to be Class "B"or better
CITY OF CUPERTINO a
WATER HEATER o -3 a-3.
CUPEkTiNO PERMIT APPLICATION FORM
APN# 37s' O� a�: ]!a1c:v
Building Address:
Owner's Name: Phone _ �7 O0
Contractor: i Phone: �o, �z License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
_
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial ❑
Cost of Project: a 1
• Strapped 0 On Platform LJ Bonded El
New Location ❑ Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
}